Therapy

Unlocking the Unconscious: 30 Years Later

Short Term Dynamic Psychotherapy promised to shorten therapy. What happened?

Posted Jul 21, 2017

David Hellerstein
Source: David Hellerstein

   Under the relentless questioning, Mr. Jones becomes more and more uncomfortable. He looms menacingly forward in his chair, as though about to pounce. Then he points to his belly. "It's right here...inside." The questions keep coming, though, one after another, and you feel that Mr. Jones is being backed into a corner, pushed closer and closer to his pain. On visiting his father, he goes on, he felt like pushing him away. He sighs.

   "You sigh," the therapist says.

   Suddenly Mr. Jones bursts into tears, and looks down.

   "You look away," the therapist says.

   Enraged, Mr. Jones glares at the therapist; he is sobbing openly now. On visiting his father, he says, he had felt the impulse to strike him, punch him in the head, in the temple, he would have killed him, broken his neck. His sobbing has reached a full burst of anguish.

   "You are describing killing your father," the therapist says quietly.

   There is a long pause.

   "I...I have a lot of terrible...terrible feelings about doing that," the man says. "That I have the power to do that..."

The tape continues, showing further sessions of once-per-week therapy over the period of about one year. Each week the therapist probes, each week Mr. Jones erupts with violent or angry feelings. The rage, so palpable at first that the man seemed about to burst from his chair and off the screen, comes up week after week, until it is just a shadow of its former self: beneath it, there is intense neediness, and the desire for tenderness and warmth.

By the time we see tapes of the last few sessions, including tapes of the man watching himself on video, seeing himself a year earlier, enormous changes have occurred. In comparison to the arrogant, spiteful, suspicious man of the first sessions, Mr. Jones now seems warm, vulnerable, utterly human. The evolution is astounding.

                                *

This text comes from my 1986 article for the magazine Science Digest, entitled “High Speed Shrinking,” which I just pulled out of the air, so to speak—finding it buried deep in the 500 GB solid-state hard drive of my 2015 MacBook Air.

This videotape was shown to a packed conference room at the Plaza Hotel, before an audience of several hundred therapists. These words take me back big-time to the mid-1980s, to what was truly a revolutionary moment in psychiatry. Short-Term Dynamic Therapy (STDP) was brief (though 40 sessions are hardly brief by today’s standards). It was highly confrontational—Davanloo kept pressing Mr. Jones until he exploded, with the goal of making major personality changes in a short time. Shockingly for therapists of that day, all sessions were videotaped for review by supervisors, and even by the patients themselves.

A startlingly compelling adaptation of Freudian methods by a dogmatic zealot, Iranian-born Canadian psychiatrist Habib Davanloo, STDP was the scandal of the day.

                *

If you are a New Yorker of a certain age you no doubt remember the 1982 New York Times Magazine article on Short-Term Dynamic Psychotherapy (STDP; Davanloo, 1980) by journalist Dava Sobel. In contrasting STDP (“the most aggressive form of psychic medicine to rest on the principles of Sigmund Freud”) to traditional psychoanalytic psychotherapy, Sobel noted, “The therapist plays an active, confrontational role, instead of the silent, supportive stance used by many psychotherapists in long-term treatment.”

By actively confronting patients’ resistances, even “badgering” them, the therapist forces the patient to address their core problems immediately, rather than waiting (often indefinitely) until they are “ready” to work seriously.

The article featured Dr. Habib Davanloo, a controversial and charismatic McGill University psychiatry professor who had developed STDP. It included an audacious comment by British psychiatrist Dr. David Malan stating that, whereas Freud had discovered the unconscious, “Davanloo has discovered how to use it therapeutically.”

In addition to its abrasive, in-your-face techniques, and its routine videotaping of sessions, STDP was remarkable for a certain branding issue: Only therapists trained by Davanloo himself—“or his disciples”—could properly perform STDP; others risked damaging the patient or worse.

While Sobel provided various caveats and critiques, readers could have easily been left to conclude that Davanloo’s STDP was going to sweep psychoanalysis into the dustbin of history. After all, why would patients be willing to put up with indefinite, potentially interminable therapy with often-dubious goals and unclear outcomes? And why would therapists want to keep seeing patients two or three (or more) times a week when they could get better results in a fraction of the time?

                    *

I’m pretty sure I didn’t read the Times Magazine article when it came out in 1982. Perhaps I was too busy with my second-year residency duties at Payne Whitney Clinic of New York Hospital. My psychiatry professors certainly would have objected to STDP on many levels: its short-term focus, the privacy-invading videotaping of sessions, and Davanloo’s outrageous claims of effectiveness, to name a few.

Perhaps, like so many attacks on psychoanalysis, it was thought best to be ignored.

I became aware of Sobel’s article only after arriving at Beth Israel Medical Center in the mid-1980s. When Davanloo announced a New York 1986 training event, I contacted my editor at Science Digest, to see if I could cover it. It couldn’t have come at a better time.

Even though I had left Payne Whitney Clinic (PWC), a bastion of psychoanalytic psychiatry, a few years earlier, I hadn’t entirely come to terms with leaving psychoanalysis behind. After all, I had chosen to enter residency training at the ultimate psychoanalytic training program. I had in some way dreamt of being an analyst. But my crisis of faith, which began almost immediately after I arrived at PWC from medical school in California, had become full-blown by 3rd year of residency.

My analytic interest had started on a literary note, from reading Freud and Carl Jung in college. I had no clue about the clinical side of it, despite a rotation at Harvard’s McLean Hospital during my 4th year of medical school, and even less of an idea what it would be like to work at an institution run by psychoanalysts.  From day one, everything at PWC had been impossible—an irreconcilable clash of temperaments. From day one until the day I left, I was always clashing with administrators and supervisors over one thing or another.

But the greatest disappointment of all was intellectual.  I found it so hard to read psychoanalytic authors. Their papers and books seemed so badly written to me: vague, rambling, jargon-ridden, gaseous, lacking crisp examples, without anything to hang your hat on. Worse, I lacked a sense of discrimination in reading their work: what was good, what was not. With literary authors like Saul Bellow, Flannery O’Connor, or Gunter Grass, I quickly could intuit whether they were great or not. Among the analysts, Bowlby and Winnicott seemed excellent, Sullivan was OK but innocuous. But in reading Adler, Klein, Kernberg, Mahler, Rank, Kohut—each had a few interesting ideas, but their words soon bored me, my mind wandered. Was it a lack of sophistication and discipline on my part? No doubt. But it was more than that: I could be utterly swayed by Kohut’s argument one week, by Kernberg’s the next.

But which was right? How could you possibly decide? Even if you read devoutly, passionately, which I couldn’t, how could you possibly tell? You also couldn’t really prove any of them wrong. The non-falsifiability of psychoanalysis—that was the ultimate intellectual buzz killer. Would there ever be any real science behind it?

                      *

When finishing psychiatry residency, I toyed with the idea of analytic training, which many of my classmates were entering.

It required something like this (each institute’s requirements differed): Several years of training analysis (starting over with a new analyst, my time with my then-therapist wouldn’t count), at least three times a week for more than 300 hours. Four or five years of classes. Four training cases treated several times a week for years, each a minimum of 200 hours, for free (fees went to the Institute), plus at least 50 hours of supervision for each case, for which the candidate, of course, paid.

In all, at least an additional four or five years of training, at a cost (in 1980s dollars) over $250,000, and then what? After all that, to then inhabit an office on the Upper East Side, to treat a handful of patients? And even so, from what my supervisors told me, I would probably have to struggle even to get a full caseload of ‘analytic cases,’ given the falling popularity of full-blown psychoanalysis by the mid-1980s.

My friends and I were already in what we called “24th grade." I wouldn’t finish “school” until the age of 35.

As psychiatry residency approached its end, I found myself studying the collected works of Freud—not the text itself, but its physical presence, the 24 volumes of The Standard Edition of the Complete Psychological Works of Sigmund Freud, edited by James Strachey, which invariably occupied several feet of shelf-space in the offices of my various supervisors, not to mention my analyst Dr. Veltrin’s.

Had they read them all?

Covered in baby blue or pale ivory dust-jackets, in some offices the books were nearly pristine, seemingly barely read. In other supervisors' offices, the dust-jackets were ragged and torn; and every so often, you'd see entirely naked cloth bindings, as though the dust jackets had been vaporized in a passion of reading. If you pulled them off the shelf, some volumes, typically the first few, had pages grimy from much handling. But even reading Freud, the master, was tolerable for me only in small doses. I couldn’t imagine tackling the Complete Works.

At times I could understand critics who called psychoanalysis a cult, or who derided the whole enterprise of training analyses, etc. as a guild, even a grand Ponzi scheme. Who criticized the field for producing so many theorists, and, after a hundred years, no outcome data. It seemed valid to complain that that era’s psychoanalysts engaged in deliberate mystification and obfuscation. I wondered how Freud, if he still was alive, and could see what psychoanalysis had become, would react. But all carping aside, I actually felt that the analysts did have something there, that there was indeed something to the method. But I just couldn't swallow the whole thing.

So I went on to other things: to community psychiatry, to psychopharmacology, eventually even to doing research.

                 *

Thirty years later, trying to reconstruct the experiences of that time, I search for memories on my hard drive. My 1986 Science Digest article, long predating the Internet, is nowhere to be found online, I couldn't locate a hard copy among boxes in my attic, and neither, at first, could I find the manuscript on my computer. (Did I even write it on a computer?) I keep searching, looking at old files that I'd dumped from one hard drive to the next.

Eventually I find it, entitled BRIEFTX.WS. More precisely, I find twenty-plus copies scattered through various folders, the result of multiple data dumps, all misdated "01-01-1980." Alas, they open into gibberish. I struggle to translate 1986 WordStar into Word for Mac 201X. It’s an archaeological process—or perhaps a psychoanalytic one. Using online text translators, eventually I recover the 1986 text, albeit written in a minuscule font, with innumerable extra spaces and strange line breaks.

It is intact but wildly distorted—like a recovered memory.

          *

And re-reading my old article, reconstructing my old memories, it all comes into focus. There was a reason I needed to find that 1986 file.

With DSM-III coming in back then--the new Diagnostic and Statistical Manual of mental disorders, third edition, which standardized diagnoses across psychiatry, and highlighted both the commonness of psychiatric illnesses, and the need to find effective treatments for tens of millions of people, it was painfully clear that there was no time for the endless silences of psychoanalysis, for a largely unaffordable and painfully slow treatment.

So the question was, could there any place for psychoanalysis in the then-new DSM-III era?

Maybe STDP could fill the gap.

Maybe a boiled-down, incredibly intense brief treatment, which was based on psychoanalytic principles, could effectively treat the masses of people in need. Back then, STPD seemed like at least a possibility, perhaps a last gasp, for the whole psychoanalytic enterprise.

Once I resize and reformat everything, my 1986 excitement comes through loud and clear: Davanloo’s clever use of ‘trial therapies’ to assess suitability for treatment, and the probing ‘transference challenges,’ Davanloo’s approach of systematically “challenging and exhausting defenses to `unlock the unconscious,'” as he put it that day.

Some things still seem fresh in that 30-plus year old article:

     “Every session is videotaped, to be reviewed later by the therapist (and his colleagues), and sometimes by the patient as well,”

And:

     “The camera, or the invisible audience, becomes a third character in what has traditionally been a totally private, two-person transaction.”

Plus, it's remarkable how the training of STDP therapists, even 30 years ago, involves the study of videotapes--like ballet dancers or NFL players. This was totally different than how we learned therapy:

"[traditionally] therapy has traditionally been taught by proxy, through the reading of abstract, often murky volumes of theory, and by supervision of the therapist-in-training by a senior therapist based on written notes made after therapy sessions. Of the great pioneering therapists, Freud, Jung, Adler, Klein, etc., virtually none of their actual work has been preserved.”

The camera seemed to be the best way out of this murk: "by using the camera [Davanloo] opens up the murky [again the word murky!] half-light of the consultation room to the grainy cinema-verite clarity of videotape. Failure and success are uniquely visible. Highly touted results can be tested by experimental methods.”

Furthermore, “because Davanloo's STDP is so highly testable (being brief, relatively simple, standardized and entirely video-recorded), it is uniquely suited to be tested experimentally against other forms of psychotherapy in psychotherapy research programs. And as a ‘dynamic’ therapy, a therapy of feelings, the natural comparison would be against cognitive or behavioral therapies, which also tend to be brief, standardized and relatively simple.”

                *

At my new hospital, Beth Israel Medical Center, just such a study was going on!

Our therapists had received Davanloo’s training and were comparing STDP to a type of cognitive therapy. It was also innovative in another way: apparently being the first large psychotherapy study to videotape all sessions of treatment. At the time, I wasn’t involved in it then, though later on I was drawn in. (Rather than STDP, I ended up working on supportive psychotherapy, which our group was to to study as an active treatment in comparison to STDP.)

It was all very revolutionary, though not in the way we may have anticipated at the time.

To make a very long story short, my new hospital’s studies comparing STDP to other approaches--our horse-races--which were published a number of years later, did not support Davanloo’s claims of the superiority of his approach.

The brief cognitive therapy did just as well as STDP.

In fact, in an analysis I myself published in the 1990s, our version of supportive therapy was equally good as, and in some areas actually somewhat superior to, STDP. (Not long afterward, our group and Davanloo’s parted ways. Were our STDP therapists inadequately trained? Improperly supervised? Were there other deficiencies in our application of the STDP treatment approach, compared to what was done in Montreal? Or was Davanloo just a master therapist whose techniques were difficult to teach? I still don’t know the whole story.)

                       *

But STDP never hit the big time.

I'm still not sure entirely why, but I have some thoughts:

For one thing, its highly confrontational approach requires that therapists have a high level of skill. Today there is more demand for therapies that can be delivered by less-highly trained therapists, often with just a few years of professional training, and learnt quickly from training manual. And STDP’s forty to fifty sessions now seems like long-term therapy; most brief therapies now are in the range of 8 to 12 sessions, often even fewer. It’s just not the way the overall field is moving. Also, the psychotherapy research enterprise has matured too: Studies now focus much more on “process” outcomes instead of head-to-head horse races—the detailed moment-by-moment interactions between therapist and patient, as well as trying to figure the characteristics of patients who may do best with specific approaches.

Nevertheless, thirty years later, STDP remains very much alive, albeit as a niche therapy rather than a world-beater. A Canadian professor, Dr. Allan Abbass, of Dalhousie University in Halifax, Canada, has done innumerable studies and reviews. By now, there is enough research to do meta-analyses, which include all relevant studies in one analysis to figure the effectiveness of one treatment compared to others. STDP, now rebranded as "ISTDP," or Intensive Short Term Dynamic Psychotherapy, appears to be most useful for certain types of ‘highly-defended’ patients--people with rigid personality styles, who haven’t responded to gentler approaches. ISTDP is no long alone as a Freudian-inspired therapy: other ‘transference-based’ therapies have emerged over the years, and are also being actively studied. To my knowledge, none is so intensely confrontational as STDP.

Even Payne Whitney’s psychiatry department eventually got into doing psychotherapy outcome studies, including a transference-focused treatment, a gentler offshoot than Davanloo’s, but psychodynamic nonetheless. I’m pretty sure they videotape sessions.

And in big cities, groups of therapists do provide STDP or ISTDP, though no doubt on a much smaller scale than Davanloo would have envisioned. On the other hand, classical psychoanalysis refuses to die: there still thousands of psychoanalysts in practice, though they continue to have difficulty finding enough patients willing to lie on the couch several times per week.

                        *

My article concluded, only slightly breathlessly:

Moreover, there is Davanloo's focus on change. For better or worse, the leisurely explorations of psychoanalysis, the plumbings of the depths of the human psyche (which has profoundly affected 20th century society, art and culture), the elaboration of fantasies, the attempt to recall murmurings from the cradle--these seem to be giving way in psychotherapy circles to an emphasis on finding the keys to change. If human change requires unlocking the door of the unconscious (and some theorists believe it does not), then the psychoanalyst has traditionally waited with superhuman patience for the door to open by itself. In contrast, Davanloo and his followers are doing their best to forge a skeleton key.

Spot on, if I do say so myself. Though I’m not sure the skeleton key has yet been found.

                        *

Also, it’s worth pointing out that residency training in psychotherapy now invariably involves videotaping, especially the twice-a-week psychoanalytically-oriented therapy cases that my Columbia Psychiatry residents now treat at the New York Psychiatric Institute.

Using webcams perched atop their flat-screen monitors, our young psychotherapy trainees digitally record every session and transfer them to encrypted flash-drives, which they then show to supervisors and classmates for review. They, and their patients, also complete rating scales, to calculate the level of symptoms of depression or anxiety, before and after treatment to determine whether treatment has helped.

Interestingly, patients sometimes initially complain about the camera, but usually they forget pretty soon that it is there.

After all, everything we do today, everywhere we go, cameras are recording us, or we are recording ourselves.

So in that way at least, the world has caught up to Davanloo.

References

Abbass, A. (2015). Reaching through resistance: Advanced psychotherapy techniques. Kansas City, MO: Seven Leaves Press.

Davanloo, H. (1980). Short-term dynamic psychotherapy. New York, NY: Jason Aronson.

Hellerstein, D. (1986) High Speed Shrinking. Science Digest

Leichsenring, F., Salzer, S., Beutel, M. E., Herpertz, S., Hiller, W., Hoyer, J. … Leibing, E. (2014). Long-term outcome of psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder. American Journal of Psychiatry, 171(10), 1074-1082. doi: 10.1037/t03750-000

Sobel, D. (1982, November 21). A new and controversial short-term psychotherapy. The New York Times Magazine. Retrieved from http://www.nytimes.com/1982/11/21/magazine/a-new-and-controversial-short-term-psychotherapy.html

Winston, Arnold, et al. "Short-term psychotherapy of personality disorders." American Journal of Psychiatry 151.2 (1994): 190-194.  

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